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The Vitality Center
Paul C. Dillon, M.D. & Paul E. West, III, PA-C
Anti-Aging Questionnaire
First Name
*
Last Name
*
Date of Birth
*
+
Gender
*
Male
Female
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
Please answer YES or NO to the following options that apply to you.
1) Are you tired throughout the day?
*
Yes
No
2) How many hours of sleep do you get a night?
*
1-2 hours
3-4 hours
5-7 hours
8-9 hours
3) Are you tired in the mornings?
*
Yes
No
4) Do you have to drink caffeine to feel energized?
*
Yes
No
5) Do you have to take supplements to feel energized?
*
Yes
No
If so, which ones?
*
6) Do you feel like you can’t exercise or play sports like you used to?
*
Yes
No
7) Does it take you longer to recover from a workout?
*
Yes
No
8) Are you forgetful?
*
Yes
No
9) Do you feel like your life is stressful?
*
Yes
No
Use 1-2 words to describe your overall mood?
*
10) Do you struggle with having “enjoyment in life”?
*
Yes
No
11) Do you have a good “work-life balance”?
*
Yes
No
12) Is your sex drive lower than it used to be?
*
Yes
No
13) Are you and your partner fulfilled when it comes to your sex life?
*
Yes
No
14) Are you able to orgasm?
*
Yes
No
Males only: Do you have trouble getting or maintaining an erection?
*
Yes
No
Please select one or more symptoms that occur frequently or disrupt your lifestyle:
*
Fatigue
Allergies
Bloating
Diarrhea
Constipation
Painful Sex
Lower Sex Drive
Memory Problems
Trouble Staying Asleep
Difficulty Falling Asleep
Trouble Completing Tasks
Trouble Focusing or Concentrating
List your allergies, or food intolerances; including reactions (i.e. shellfish - hives)
*
15) Is weight an issue for you?
*
Yes
No
16) Have you recently lost weight?
*
Yes
No
17) Have you recently gained weight?
*
Yes
No
18) Do you exercise?
*
Yes
No
If yes, how often and what type?
*
19) Have you experienced a decrease in or inability to maintain muscle mass?
*
Yes
No
20) Have you tried any programs or medications to help lose weight?
*
Yes
No
If yes, which ones?
*
21) Do you feel like you eat a well-balanced diet?
*
Yes
No
22) Are you happy with the way you eat?
*
Yes
No
23) Do you have an issue controlling cravings?
*
Yes
No
24) Do you have trouble feeling full?
*
Yes
No
25) Do you eat more when you are stressed?
*
Yes
No
26) Have you had any recent changes in your stool?
*
Yes
No
27) Do you feel like you have trouble digesting certain foods?
*
Yes
No
If so, which ones?
*
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